Individual
JOHN M PROVENZA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
8383 MILLICENT WAY STE B, SHREVEPORT, LA 71115
(318) 631-9121
(318) 213-6246
Mailing address
3217 MABEL ST, SHREVEPORT, LA 71103-4022
(318) 631-9121
(318) 631-9126
Taxonomy
Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
017860
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1376442
—
LA
01
—
MD.017860
STATE LICENSE
LA
Enumeration date
10/27/2005
Last updated
08/12/2022
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